Scheduled Bulk SMS Program as Hypertension Education Media and

Medication Reminder in Puskesmas 2 East Denpasar

Hari Purnomo

, Fariz Afristya Putra

and Anindya Agripina Hadyanawati

Industrial Engineering, Universitas Islam Indonesia, Sleman, Yogyakarta, Indonesia

Field Epidemiology, Universitas Udayana, Denpasar, Bali, Indonesia

Keywords: Automated, Text Messaging, Medication, Adherence, Health Education, Hypertension

Abstract: This research is an operational research aimed to evaluate ongoing scheduled bulk SMS program in

Puskesmas 2, East Denpasar. The evaluation comprised of health education media and medication reminder.

Research was held prospectively with multiple posttest method. Within one-year evaluation of program

implementation, 90 people satisfy the research criteria and managed to follow the procedure to the end of

research. Questionnaire result from four examination (pretest and three times posttest) statistically analyzed

using ANOVA with repeated values. Research result showed that scheduled bulk SMS Program statistically

significant to improve perception about their medication regiment (as a health education media) (F (1.928;

171.594) = 171.509, p<0.005), and statistically significant to increase medication adherence (as a medication

reminder) (F (2.495; 222.092) = 149.293; p<0.005).

1 INTRODUCTION

Cardiovascular disease mainly caused or made

worse by uncontrolled high blood pressure, even

some research boldly stated that blood pressure is

directly correlated with cardiovascular mortality risk

(Lewington et al., 2002). Importance of controlling

blood pressure emphasized when it was found that

cardiovascular disease chance is decreased when

patient manage to control their blood pressure

(Staessen, Wang and Thijs, 2001; Staessen et al.,

2005) independently whether the patient manage to

control their obesity and diabetes or not (Anand and

Yusuf, 2011).

Management of high blood pressure is not as

simple as taking medicine to treat the disease. Two

important management need to be done daily to

maintain low blood pressure, which are daily

adherence to suggested blood pressure medication

(Neal et al., 2000), and life style changes to eliminate

risk factors, such as alcohol and smoking (Whitworth

and World Health Organization, 2003; Staessen et al.,

2005). Those two-management synergy needs to be

maintained in long term to decrease cardiovascular

disease morbidity and mortality.

A lot of intervention already been used to improve

adherence, both for treatment and life style change

with mixed and varying result (Haynes et al., 2008).

Lately medical treatment trend also undergoes

digitalization. With worldwide access of mobile

phone, lately it’s more difficult to find patient with no

access to mobile phone. Mobile phone already used

before as medication support, lifestyle education

delivery, discussion media with health care providers,

or independent individual searches of health issues in

Internet (Heron and Smyth, 2010).

According to Indonesia’s Ministry of

Communication and Informatics by the end of 2017,

371.4 million people have already had access to

mobile phone, this is very big, considering total

population of Indonesia at the time were 262 million

(Kementerian Komunikasi dan Informatika Republik

Indonesia, 2019). That means 142% of Indonesian

population have access to personal communication

device by the end of 2017 or on average 1.4 phones

per person. This is possible as more and more people

have multiple phone for different purposes. Further

reading showed that only around 43% of that

population have access to internet and social media,

that means only half of Indonesia population have

smartphones (Statista, 2019). As access of

smartphones are limited, basic mobile phone services

(phone calls, or short message services) are probably

have better penetration compared with internet-based

services.

Purnomo, H., Putra, F. and Hadyanawati, A.

Scheduled Bulk SMS Program as Hypertension Education Media and Medication Reminder in Puskesmas 2 East Denpasar.

DOI: 10.5220/0009352900250032

In Proceedings of the International Conferences on Information System and Technology (CONRIST 2019), pages 25-32

ISBN: 978-989-758-453-4

Researches based on Short Message Service

(SMS) to improve adherence have varying result

worldwide, but so far writer haven’t found proper

similar research in Indonesia. To name a few,

significant research result are from Russia (Kiselev et

al., 2012), China (Lin et al., 2014), and South Korea

(Park and Kim, 2012). Not significant results are from

Pakistan (Mohammed, Glennerster and Khan, 2016),

Spain (Márquez Contreras et al., 2004; Carrasco et

al., 2008), and Philippines (Philipines Department of

Health, 2017). As previous researches were not

yielding coherence and similar result, writer speculate

there are region specific causes that causes different

results. Parallel with writer’s speculation, similar

effort to improve adherence using SMS is performed

by one of primary health care (puskesmas) in

Denpasar, Bali. Writer then collaborate with said

primary health care to evaluate program’s result.

2 MATERIALS AND METHODS

2.1 Participants, Questionnaire, and

SMS Program

Research subjects are all patients treated in

Puskesmas 2, East Denpasar who meet the research

criteria. Inclusion criteria were as follows: (1) over 18

years old (2) diagnosed as hypertension patient (3)

receiving drugs and medication from Puskesmas 2,

East Denpasar (4) literate, able to read (5) possess cell

phone / smartphone. Exclusion criteria are also added

to prevent result alteration: (1) palliative patient with

life expectancy under one-year (2) patient also

diagnosed with other chronic illnesses (diabetes,

cancer, COPD) (3) dementia or with severe mental

disorder. Control group was not formed, as this

research is an evaluation of Puskesmas’ new program

to promote health, so all patients are included in the

program. This attempt to increase treatment

adherence were one of Puskesmas’ innovation in

yearly Outstanding Puskesmas contest.

There were two questionnaires used in this

research, one for evaluating subject’s attitude about

their medication regiment, and one for evaluating

subjective medical adherence of each patient.

Assessing attitude and knowledge of research

subjects done using Indonesian adaptation of 30

questions Drug Attitude Inventory (DAI30) (Hogan,

Awad and Eastwood, 1983). Adherence to

medication was scored using Morisky’s 8 Items

Medication Adherence Scale (MMAS-8) (Morisky et

al., 2008). These two-questionnaire tested for validity

and reliability after translation, resulted in no needs

for further editing aside from translation into

Indonesian language.

Scheduled bulk SMS program were not built by

writer, the program used was paid Android phone

(Google, 2019) based program named Pulse (Klinker,

2019). Pulse was selected because of their useful

feature within scope of this research. Features used in

this research are: (1) scheduled SMS (2) bulk SMS

option and grouping (3) repeat SMS option (4)

automatic response by sender and by keyword (5)

scheduling can be performed with other devices

without changing phone number.

2.2 Research Procedure

This is an operational research using prospective

analytic research with multiple posttest method

without control group, held within February 2018

until February 2019 time span. All hypertension

patients who came to check their health and procuring

routine medicine in February 2018 (28 days) are

invited into this research, before continuing, they are

screened through inclusion criteria, exclusion criteria,

and signing informed consent. Patients unwilling to

join with any reason are convinced that they’re going

to have the same treatment as usual with patients who

joins this research. This was to ensure that no patient

feels forced to join, while medical adherence is also

affected by patient’s willingness to follow up through

their treatment regimen.

Patients who join this research then interviewed

for their demographic data (including age, sex,

marriage status, education status, occupation, health

insurance, medication used, medical complication,

phone number, type of phone used, and phone signal

around home), and baseline data as a pretest score

using adapted DAI30 (patient’s attitude toward their

medication) and MMAS-8 (patient’s adherence

toward their medication) into Indonesian language.

After one-month process of screening and

acquiring baseline pretest data in February 2018,

scheduled bulk SMS program were performed.

Patients are grouped by what kind of medications are

they on, and date of follow up to puskesmas for their

illness, then they will get targeted SMS based on their

group to help improve their treatment adherence. For

education purpose, patients are not grouped and

receiving the same SMS. There are several types of

SMS patients receive throughout this research those

are:

 Reminder for medication time (specific for

each patient’s medication regiment)

 Reminder for illness follow up to puskesmas

date and procuring more medicine (SMS sent

CONRIST 2019 - International Conferences on Information System and Technology

five days, three days, and one day before

following up date for each patient)

 Short education about illness they suffer,

medication taken, and healthy lifestyle (3-4

times per week)

Evaluation to check whether SMS sent manage to

affect perception towards treatment regimen and

medication adherence (posttest) was done three times,

on June 2018, September 2018 and February 2019.

Software used to analyze pretest and posttest data are

Ms. Excel (Microsoft, 2019) and SPSS (IBM, 2019).

Statistical analysis was done using ANOVA with

repeated measures to know whether any data changes

between test are statistically significant or not.

Demographic descriptive analysis data will be

presented as is, or as percentage.

3 RESULT AND DISCUSSION

3.1 Research Participants

Within one month of collecting baseline data, 98

patients are registered to join this research, but only

90 patients (91%) are able to finish through all

posttest. From those eight people who didn’t manage

to finish this program, one died, one admitted to

hospital because of stroke, and six lost to follow up.

Table 1 shows demographic and baseline data of

research participants who managed to join the

program for one full year and finished three follow

ups.

Table 1. Baseline Characteristics, n=90

Age

Mean

Std Deviation

Range

(Y.O)

53.3

14.2

30-79

Years

Diagnosed

Mean

Std Deviation

Range

(year)

3.5

2.2

1-9

Sex

Male

Female

35.6%

64.4%

Complication

Yes

34.4%

65.6%

Marriage

Not Married

Married

Widowed

6.7%

58.9%

34.4%

Ever Change

Medication

Yes

23.3%

76.7%

Education

None

Elementary

Junior High

Senior High

Bachelor

Post Grad.

15.6%

31.1%

25.6%

15.6%

10.0%

2.2%

Phone Type

Handphone

Smartphone

61.1%

38.9%

Occupation

Informal

Private Sect.

Civil Sector

Professional

Entrepreneur

Unemployed

34.4%

22.2%

5.6%

8.9%

11.1%

17.8%

Bad Phone

Signal

Yes

Sometimes

20.0%

70.0%

10.0%

Medication

Amlodipine

Captopril

20%

80%

Keep Phone

Near

Yes

53.3%

46.7%

3.2 Drug Attitude Inventory

Drug Attitude Inventory is an adapted

questionnaire used to define patient’s perception and

their level of trust to medication. Higher score

associated with higher level of trust, and vice versa,

lower score associated with lower level of trust to

their medication. Figure 1 and Table 2 are boxplot

and mean table for four data result (pretest, posttest 1,

posttest 2, posttest 3) using this questionnaire.

Fig. 1. DAI 30 Mean Result

Table 2. DAI 30 Descriptive Statistics

Mean

Std.

Dev.

N of

Max

Score

Δ with

prior

exam.

Pretest

17.066

4.7612

Posttest 1

21.588

5.1970

4.5222

Posttest 2

23.355

5.4511

1.7667

Posttest 3

23.844

5.8883

0.4888

Boxplot diagram shows that there was

considerable elevation of score from pretest to

posttest 1. However, the increment of score result

tends to decrease in posttest 2 and become negligible

in posttest 3. With continuous increment of mean

score within this research, ANOVA with repeated

measure was performed to ensure whether those

increment are statistically significant or not. Table 3-

5 shows the result of said statistical analysis:

Scheduled Bulk SMS Program as Hypertension Education Media and Medication Reminder in Puskesmas 2 East Denpasar

Table 3. DAI 30 Mauchly's Test of Sphericity

Within Subjects Effect Mauchly's W

Approx. Chi-Square

df Sig.

Epsilon

Greenhouse-Geisser

Huynh-Feldt

Lower-bound

Time

0.415

77.148

0.000

0.643

0.657

0.333

Table 4. DAI 30 Anova with Repeated Measures

Source

Type III Sum of Squares

Mean Square

Sig.

Partial Eta Squared

Time

Greenhouse-Geisser

2573.697

1.928

1334.891

171.509

.000

.658

Error (Time)

Greenhouse-Geisser

1335.553

171.594

7.783

Table 5. DAI 30 Bonferroni Post Hoc

(I) Time

(J) Time

Mean Difference

(I-J)

Std. Error

Sig.

95% Confidence Interval for Difference

Lower Bound

Upper Bound

-4.522

.307

.000

-5.351

-3.693

-1.767

.242

.000

-2.419

-1.114

-.489

.227

.206

-1.103

.125

Mauchly's Test of Sphericity (Table 3)

indicated that the assumption of sphericity had been

violated (X

=0.415, p<0.005). Because sphericity had

been violated, Anova with repeated measure result

should be corrected. Greenhouse-Geisser correction

was chosen because it resulted in epsilon of 0.643.

Greenhouse-Geisser adjustment on ANOVA

with repeated measure result shows, in general mean

value of DAI30 statistically differs between each

examination time (F (1.928; 171.594) = 171.509,

p<0.005) (Table 4). Mean score increment of DAI30

are observeable from pretest until all three posttest as

can be seen on Table 2, respectively, 17.1±4.8;

21.6±5.2; 23.4±5.5 ; 23.8±5.9.

However, even though increment may always

be observed, not all of them are statistically

significant (Table 5). Significant score increase can

be seen on pretest to posttest 1 with mean difference

of -4.522±0.307 (p<0.005), and posttest 1 to posttest

2 -1.767±0.243 (P<0.005), unfortunately score

difference between posttest 2 and posttest 3 is not

significantly differs -0.489±0.227 (p=0.206).

As statistical analysis result showed,

scheduled bulk SMS program has better efficacy on

the beginning of program, and slowly recede towards

the end of 1-year period. However, this probably

happened because max score of DAI30 questionnaire

already reached by most subjects by the end of

research, this leads to stagnation of mean score as no

additional score may be achieved by subjects.

Perhaps further research should be performed to

establish whether after program ended, patient still be

able to maintain their high attitude toward

medication, or perhaps this program should be

continued to maintain program result.

3.2 Morisky’s Eight Items Medical

Adherence

Morisky’s Eight Item Medical Adherence

measures patient’s medication adherence. Different

with DAI30, M8MA score interpreted as better if

lower score is achieved. This because M8MA asks

about factors that promote medication

inconsistencies, more factors helped inconsistencies

means worse medication adherence rate. Below is

boxplot diagram and mean result of M8MA

questionnaire from pretest to the third posttest.

Fig. 2. M8MA mean result

Table 6. M8MA Descriptive Statistics

Mean

Std.

Dev.

N of

Max

Score

Δ with

prior

exam.

Pretest

3.0078

1.21070

Posttest 1

2.6000

1.50505

0.4078

Posttest 2

1.7444

1.53287

0.8556

Posttest 3

0.6778

1.22546

1.0666

As can be seen from previous Figure 2 and

Table 6, score reduction always happened between

time period, and the difference keeps getting larger

after each posttest. Even from pretest, there was

already one sample with max adherence, and the

CONRIST 2019 - International Conferences on Information System and Technology

number of patients with max adherence keeps

gradually increasing towards the end of research.

Mean scores are pretest 3.0078±1.21070, posttest 1

2.6000±1.50505, posttest 2 1,7444±1.53287, and

posttest 3 0.6778±1.22546.

Mauchly’s test of sphericity in Table 7

indicates that the assumption of sphericity had been

violated, with result of X

=0.635; p<0.005. Huynh-

Feldt correction is chosen to adjust result of ANOVA

with repeated measures as it produced epsilon of

0.832.

ANOVA with repeated measures with Huynh-

Feldt correction (Table 8) shows that mean score of

M8MA statistically differs between each examination

time (F (2.495; 222.092) = 149.293; p<0.005).

Significant score reduction of M8MA (increasing

adherence) are observed via Post Hoc test using

Bonferroni correction on all four tests performed

(Table 9). The score difference are 0.478±0.111

(p<0.005) between pretest and posttest 1,

0.856±0.093 (p<0.005) between posttest 1 and

posttest 2, lastly 1.067±0.107 (p,0.005) between

poosttest 2 and posttest 3.

This program tends to have better effect on

M8MA score approaching the end of research, with

more than 50% of patient managed to get full

adherence by the end of research. This result differs

with DAI30 that have better score increment in the

beginning of research.

3.2 Discussions

Scheduled bulk SMS program have positive

effect to patient’s perception of their medication

(DAI8) as well as the level of medication adherence

(M8MA). However, said positive effect seems have

different pattern in long term and long term. DAI8’s

score increment tends to decrease along the time

points (Δ pretest-posttest 1 = 4.5222; Δ posttest 1-

posttest 2 = 1.7667; Δ posttest 2-posttest 3 = 0.4888).

Meanwhile, SMS manage to increase patient’s

adherence better in long run (Δ pretest-posttest 1 =

0.4078; Δ posttest 1-posttest 2 = 0.8556; Δ posttest 2-

posttest 3 = 1.0666).

This difference of effect by time period may

have happened because there are different

fundamental goals of SMS program between

educating and reminding patients. Education

functions as new information giver thus may lead to

saturated information, in which no new information

are received by patients. Reminder on the other hand,

is aimed to help patient remember when to take their

medication, so repeated exposure may help increase

adherence better.

Similar approach of study based around SMS

to improve adherence tends to have various result.

Further reading suggested that SMS program have

better effect on medication adherence in a large

countries such as Russia (Kiselev et al., 2012) and

China (Lin et al., 2014). Smaller countries inclined to

have less positive effect from SMS intervention, such

as research in Spain (Carrasco et al., 2008) (Márquez

Contreras et al., 2004), Pakistan (Mohammed,

Glennerster and Khan, 2016), and Philippines

(Philipines Department of Health, 2017). Other factor

that may influence research is length of study, better

result can be observed in research with more than six

months intervention (Kiselev et al., 2012; Lin et al.,

2014; Márquez Contreras et al., 2019) compared with

less than six months intervention (Márquez Contreras

et al., 2004; Philipines Department of Health, 2017).

Table 7. Mauchly's Test of Sphericity

Within Subjects

Effect

Mauchly's W Approx. Chi-Square

df Sig.

Epsilon

Greenhouse-Geisser

Huynh-Feldt

Lower-bound

Time

.635

39.882

.000

.808

.832

.333

Table 8. M8MA Anova with Repeated Measures

Source

Type III Sum of Squares

Mean Square

Sig.

Partial Eta Squared

Time

Huynh-Feldt

299.942

2.495

120.197

149.293

0.000

0.627

Error (Time)

Huynh-Feldt

178.808

222.092

0.805

Table 9. M8MA Post Hoc Bonferonni

(I) Time (J) Time Mean Difference (I-J) Std. Error Sig.

95% Confidence Interval for Difference

Lower Bound

Upper Bound

0.478

0.111

0.000

0.179

0.777

0.856

0.093

0.000

-.605

1.106

1.067

0.107

0.000

0.778

1.355

Scheduled Bulk SMS Program as Hypertension Education Media and Medication Reminder in Puskesmas 2 East Denpasar

Previous researches support our research

result, Indonesia is a large country with thousands of

islands (Nurul Fitri Ramadhani, 2017), this leads to

better SMS reach area compared with countries with

smaller area. As previously mentioned in

introduction, SMS was chosen as media because of its

accessibility and cost. This research also reinforces

previous research result that longer intervention by

SMS performed evidently helped patients to maintain

their medication adherence.

There are several research limitations that

needs to be considered. First one is presence of outlier

data in this research. With the ongoing increment

score of DAI30 there were always outliers with very

low score along the research, similar with DAI30,

M8MA also have several outliers within the group but

writer notices different pattern of outlier. DAI30 have

outliers on all time points from pretest to the third

posttest, but in M8MA outliers only happened on

second and third posttest. By analyzing bottom 5

score acquirer, there are at least two people that

constantly getting low score. Furthermore, their

scores are not constantly increasing as other

participants do.

There are several possible reasons why this

happened, language barrier, weak comprehension to

the questions and laziness and/or ignorance to follow

order of research. Language barrier happened because

even though the questionnaire already translated into

Indonesian language, and Indonesian language is the

national language in the country, there are minority of

the population (especially geriatrics) who only

understand local languages (Cohn and Ravindranath,

2014). Geriatrics also have other problems aside from

language disparity that affects questionnaire result,

such as vision degeneration (Saw et al., 2003),

cognitive impairment (Mardiyanto, Jahja and

Limyati, 2017), or both (Ong et al., 2012). Other

factor author managed to grasp was laziness of the

respondents. With total of 38 questions to answer -if

each question is to be read in at least 15 until 30

seconds- respondents needs at least 10 minutes to

finish, but there are several respondents that submit

the paper within 2-3 minutes. This may be because of

laziness or ignorance to the questionnaire result.

Further research should address the same problem if

happened by eliminating those samples or performing

in depth interview to understand factors affecting

program efficacy.

Second research limitation is there were no

control group in this research because the nature of

this research as an operational research to evaluate

ongoing program performed on all patient in the

primary health care. Third research limitation is this

research only performed in one health center. Second

and third research limitation may be diminished by

larger research on multiple health center using

randomized controlled trial.

4 CONCLUSION

To conclude this research, scheduled bulk

SMS program is statistically significant to increase

DAI30 score (increase medication perception) and

decrease M8MA score (increase medication

adherence) (F (1,928; 171,594) = 171,509, p<0,005

and F (2,495; 222,092) = 149,293; p<0,005

respectively). This program is advised to be adapted

in larger scale and longer term, seeing SMS program

inclined to perform better in larger area and

continuously. Since this method have high

effectiveness despite the low cost, primary health care

may be able to deliver better result compared with

secondary and tertiery health center or hospital, as

most long-term treatment of chronic illnesses patients

are treated within the scope of primary health care.

COMPETING INTEREST

Authors hereby declare that they have no

competing interests.

ACKNOWLEDGEMENTS

We are grateful to all patients who

participated, all health care workers in Puskesmas II

East Denpasar, especially to the doctors: dr. I Made

Buda Wisnawa, M.Kes.; dr. Anik Rosida ; dr. Ni

Wayan Kandita Arumdani. Also we are grateful to

Pulse Software developer Luke Klinker for giving us

permission to use the software.

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